Dermatology Book

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Acne RosaceaAka: Rosacea, Rhinophyma

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  1. Epidemiology
    1. Most common in ages 30 to 50 years old
    2. Northern european descent
    3. More common in women by factor of 2-3
  2. Definition
    1. Acneiform eruption
  3. Predisposing conditions
    1. Sun Exposure, hot weather, and hot baths
    2. Emotional stressors
    3. Alcohol
    4. Hot drinks
    5. Exercise
    6. Nose Hair Follicle mites (Demodex folliculorum)
  4. Symptoms
    1. Stinging pain may accompany facial Flushing
  5. Signs
    1. Course is variable
      1. Stages listed below are for organization only
    2. Distribution for all lesions
      1. Affects middle third of face (forehead to chin)
    3. Stage 1: Initial presentation
      1. Intermittent facial Flushing
    4. Stage 2: Early vascular changes
      1. Facial erythema
      2. Telangiectasis
      3. Eye changes (see ocular signs below)
    5. Stage 3: Inflammatory changes
      1. Papules
      2. Sterile Pustules
      3. Comedones are typically absent
    6. Stage 4: Rhinophyma (Red bulbous nose)
      1. More common in men
      2. Thickening of facial skin (especially nose)
        1. Connective tissue hypertrophy
        2. Sebaceous Gland hypertrophy
      3. Previously thought to be a sign Alcohol Abuse
        1. Example: W. C. Fields
    7. Variant: Granulomatous Rosacea
      1. May appear similar to facial sarcoid
  6. Signs: Ocular involvement (50% of rosacea cases)
    1. Eyelid Inflammation (may be presenting sign)
      1. Acne involving eyelids
      2. Eyelid redness and swelling
      3. Eyelid margin telangiectasia
    2. Inflammatory Conjunctivitis
      1. Blepharitis may accompany Conjunctivitis
      2. Eyes that itch or burn
      3. Dry eyes with sandpaper or foreign body sensation
    3. Other less common changes
      1. Corneal neovascularization
      2. Keratitis
      3. Corneal scarring
  7. Differential Diagnosis
    1. Late-onset Acne Vulgaris
      1. Comedones present
      2. No telangiectasis
      3. No eye symptoms or signs
    2. Steroid-induced Acne
      1. Results from Corticosteroid use on face
      2. Perioral changes
    3. Perioral Dermatitis
    4. Polymorphous Light Eruption
    5. Systemic Lupus Erythematosus
    6. Allergic Conjunctivitis
    7. Seborrheic Dermatitis
    8. Carcinoid Syndrome (severe facial Flushing)
  8. Management: General Measures
    1. Avoid Alcohol
    2. Avoid prolonged heat exposure
    3. Avoid hot liquids (coffee, tea)
    4. Avoid heavy cosmetics
    5. Use sun screen regularly
      1. Simethicone or cyclomethicone may be preferred
    6. Avoid provocative medications
      1. Benzoyl Peroxide
      2. Topical Corticosteroids
  9. Management: Papular and pustular Rosacea
    1. Step 1
      1. Apply across entire face
      2. First Line agents
        1. Metronidazole topical gel (80% effective)
        2. Azelaic Acid (Azelex) 15% gel
          1. Slight benefit over Metrogel, but less tolerated
          2. Elewski (2003) Arch Dermatol 139:1444
      3. Alternative agents
        1. Clindamycin (Cleocin-T)
        2. Permethrin 5% cream
          1. Kocak (2002) Dermatology 205:265
    2. Step 2
      1. Oral Antibiotics for 1 month, then taper dose
        1. Tetracycline 250 mg bid or
        2. Doxycycline 100 mg bid
        3. Erythromycin 250 mg bid
      2. Efficacy
        1. Useful in treating Blepharitis, Keratitis
        2. Most effective treatment
    3. Step 3: Refractory Cases
      1. Topical Tretinoin (Retin A)
        1. May exacerbate erythema and telangiectasis
      2. Isotretinoin Accutane for 20 weeks
        1. Variably effective
      3. Consider mite or tinea management
        1. Examine sample with Potassium Hydroxide
        2. Crotamiton (Eurax)
  10. Management: Associated conditions
    1. Facial Flushing and Erythema
      1. First-line: See general measures above
      2. Second-line
        1. See Vasomotor Symptoms of Menopause
        2. Clonidine 0.05 mg bid
        3. Propranolol (Inderal LA) 80 mg PO qd
    2. Telangiectasis
      1. Green-tinted cosmetics
      2. Pulsed dye laser
    3. Ocular changes
      1. First-line therapy
        1. Oral Tetracycline or Doxycycline
        2. Artificial tears for eye dryness
        3. Topical metrogel to eyelid if involved
      2. Second-line therapy for refractory cases
        1. Ocular steroids (by ophthalmology)
        2. Isotretinoin Accutane
    4. Rhinophyma
      1. Early cases: Antibiotics as listed above
      2. Advanced cases: Surgery
        1. Dermabrasion
        2. Hypertrophic tissue excision
  11. References
    1. Habif (1996) Clinical Dermatology, p. 182-4
    2. Blount (2002) Am Fam Physician 66(3):435
    3. Zuber (2000) Prim Care 27(2):309

Rhinophyma (C0035466)

Definition (MSH)A manifestation of severe ROSACEA resulting in significant enlargement of the NOSE and occurring primarily in men. It is caused by hypertrophy of the SEBACEOUS GLANDS and surrounding CONNECTIVE TISSUE. The nose is reddened and marked with TELANGIECTASIS.
ConceptsDisease or Syndrome (T047)
ICD9695.3
EnglishHypertrophic rosacea, Rhinophyma, Rhinophymas
Spanishrinofima, rosacea hipertrofica
Parent Conceptsrosacea (C0035854), Sebaceous Gland Diseases (C0036502), Non-Neoplastic Nasal Cavity Disorder (C1335021), Disorder of external nose (C0339847)
SourcesCOSTAR, MSH, MTH, MTHICD9, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


rosacea (C0035854)

Definition (MSH)A cutaneous disorder primarily of convexities of the central part of the FACE, such as FOREHEAD; CHEEK; NOSE; and CHIN. It is characterized by FLUSHING; ERYTHEMA; EDEMA; RHINOPHYMA; papules; and ocular symptoms. It may occur at any age but typically after age 30. There are various subtypes of rosacea: erythematotelangiectatic, papulopustular, phymatous, and ocular (National Rosacea Society's Expert Committee on the Classification and Staging of Rosacea, J Am Acad Dermatol 2002; 46:584-7).
ConceptsDisease or Syndrome (T047)
ICD9695.3
EnglishAcne erythematosa, Acne Rosacea, Acne roscea, rosacea
Spanishacne eritematosa, acne rosacea, rosacea
Parent ConceptsErythema (C0041834), skin disorder (C0037274), Acneiform Eruptions (C0175167), rosacea (C0035854), Sebaceous Gland Diseases (C0036502), Erroneous concept (C1274015)
SourcesCOSTAR, CST, DXP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, MTHICD9, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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